Urban–rural disparity in global estimation of PM2·5 household air pollution and its attributable health burden
Authors: Nahid Mohajeri, Shih-Che Hsu, James Milner, Jonathon Taylor, Gregor Kiesewetter, Agust Gudmundsson, Harry Kennard, Ian Hamilton, Mike Davies
Journal: The Lancet Planetary Health (2023)

BackgroundPolluting fuels and inefficient stove technologies are still a leading cause of premature deaths worldwide, particularly in low-income and middle-income countries. Previous studies of global household air pollution (HAP) have neither considered the estimation of PM2·5 at national level nor the corresponding attributable mortality burden. Additionally, the effects of climate and ambient air pollution on the global estimation of HAP-PM2·5 exposure for different urban and rural settings remain largely unknown. In this study, we include climatic effects to estimate the HAP-PM2·5 exposure from different fuel types and stove technologies in rural and urban settings separately and the related attributable global mortality burden.MethodsBayesian hierarchical models were developed to estimate an annual average HAP-PM2·5 personal exposure and HAP-PM2·5 indoor concentration (including both outdoor and indoor sources). Model variables were selected from sample data in 282 peer-reviewed studies drawn and updated from the WHO Global HAP dataset. The PM2·5 exposure coefficients from the developed model were applied to the external datasets to predict the HAP-PM2·5 exposure globally (personal exposure in 62 countries and indoor concentration in 69 countries). Attributable mortality rate was estimated using a comparative risk assessment approach. Using weighted averages, the national level 24 h average HAP-PM2·5 exposure due to polluting and clean fuels and related death rate per 100 000 population were estimated.FindingsIn 2020, household use of polluting solid fuels for cooking and heating led to a national-level average personal exposure of 151 μg/m3 (95% CI 133–169), with rural households having an average of 171 μg/m3 (153–189) and urban households an average of 92 μg/m3 (77–106). Use of clean fuels gave rise to a national-level average personal exposure of 69 μg/m3 (62–76), with a rural average of 76 μg/m3 (69–83) and an urban average of 49 μg/m3 (46–53). Personal exposure-attributable premature mortality (per 100 000 population) from the use of polluting solid fuels at national level was on average 78 (95% CI 69–87), with a rural average of 82 (73–90) and an urban average of 66 (57–75). The average attributable premature mortality (per 100 000 population) from the use of clean fuels at the national level is 62 (54–70), with a rural average of 66 (58–74) and an urban average of 52 (47–57). The estimated HAP-PM2·5 indoor concentration shows that the use of polluting solid fuels resulted in a national-level average of 412 μg/m3 (95% CI 353–471), with a rural average of 514 μg/m3 (446–582) and an urban average of 149 μg/m3 (126–173). The use of clean fuels (gas and electricity) led to an average PM2·5 indoor concentration of 135 μg/m3 (117–153), with a rural average of 174 μg/m3 (154–195) and an urban average of 71 μg/m3 (63–80). Using time-weighted HAP-PM2·5 indoor concentrations, the attributable premature death rate (per 100 000 population) from the use of polluting solid fuels at the national level is on average 78 (95% CI 72–84), the rural average being 84 (78–91) and the urban average 60 (54–66). From the use of clean fuels, the average attributable premature death rate (per 100 000 population) at the national level is 59 (53–64), the rural average being 68 (62–74) and the urban average 45 (41–50).InterpretationA shift from polluting to clean fuels can reduce the average PM2·5 personal exposure by 53% and thereby lower the death rate. For all fuel types, the estimated average HAP-PM2·5 personal exposure and indoor concentrations exceed the WHO's Interim Target-1 average annual threshold. Policy interventions are urgently needed to greatly increase the use of clean fuels and stove technologies by 2030 to achieve the goal of affordable clean energy access, as set by the UN in 2015, and address health inequities in urban–rural settings.FundingWellcome Trust, The Lancet Countdown, the Engineering and Physical Sciences Research Council, and the Natural Environment Research Council.